Impact of IT-enabled Intervention on MRI Use for Back Pain

Abstract

Background Examine the impact of a multi-faceted, clinical decision support (CDS)-enabled intervention on magnetic resonance imaging (MRI) use in adult primary care patients with low back pain. Methods After a baseline observation period, we implemented a CDS targeting lumbar-spine MRI use in primary care patients with low back pain through our computerized physician order entry (CPOE) as well as two accountability tools: 1) mandatory peer-to-peer consultation when test utility was uncertain and 2) quarterly practice pattern variation reports to providers. Our primary outcome measure was rate of lumbar-spine MRI use. Secondary measures included utilization of MRI of any body part, comparing to that of a concurrent national comparison, as well as proportion of lumbar-spine MRI performed in the study cohort that was adherent to evidence-based guideline. Chi-square, t-tests, and logistic regression were used to assess pre- and post-intervention differences. Results In the study cohort, pre-intervention, 5.3% of low back pain-related primary care visits resulted in lumbar-spine MRI compared to 3.7% of visits post-intervention (p<0.0001, Adjusted Odds Ratio 0.68). There was a 30.8% relative decrease (6.5% vs. 4.5%, p<0.0001, Adjusted Odds Ratio 0.67) in the use of MRI of any body part by the primary care providers in the study cohort. This difference was not detected in the control cohort (5.6% vs. 5.3%, p=0.712). In the study cohort, adherence to evidence-based guideline in the use of lumbar-spine MRI increased from 78% to 96% (p=0.0002). Conclusions CDS and associated accountability tools may reduce potentially inappropriate imaging in patients with low back pain.

Yield of CT Pulmonary Angiography in the Emergency Department When Providers Override Evidence-based Clinical Decision Support

“…Our findings are consistent with those of earlier studies that reported that CDS interventions that allow simple override are unlikely to optimize provider behavior during the imaging ordering process (33). Stronger interventions, such as requiring clinical justification for overriding CDS alerts (34), implementing physician performance feedback reports (35), or requiring real-time peer-to-peer consultation for providers who ignore evidence presented in CDS alerts (36), have increased adherence to evidence presented in CDS. Mandating d-dimer testing before CT pulmonary angiography for patients unlikely to have PE may be another potential strategy to further reduce the unnecessary use of CT pulmonary angiography.…”

JOURNAL CLUB: Requiring Clinical Justification to Override Repeat Imaging Decision Support: Impact on CT Use

“…Our findings support the notion that these information-only CDS interventions are unlikely to optimize provider test-ordering practices [20, 21]. A few interventions use a “hard stop,” preventing users from placing orders that conflict with evidence presented in the CDS until completion of additional, more intrusive software-enabled workflows, such as requiring responsible clinicians to personally log in and order examinations rather than relying on proxy ordering by nonclinician support staff [5] or mandating peer-to-peer consultation to override alerts [6]. However, those who implement CDS are cautioned to avoid hard stop interventions in all but the most dire circumstances [22] because physicians strongly resist such interventions [23] and are more likely to ignore serious, life-threatening alerts when alert presentation does not differ by potential clinical impact [24].…”

“…In medical imaging, CDS tools are typically triggered at the time of order entry to guide ordering providers in selecting the optimal imaging strategy (or no imaging at all) [1]. Although best practices for effective imaging CDS may be debated, the successful implementation and early impact of CDS, including systems guiding imaging orders [2–6], has led to the incorporation of CDS provisions into two sets of federal regulations. The first provides modest financial incentives for adoption of CDS as a major focus of meaningful-use stage II regulation for health care information technology [7], and the second mandates the use of imaging CDS for targeted ambulatory procedures beginning January 1, 2017, as part of the Protecting Access to Medicare Act of 2014 [8].…”

Effectiveness of interventions designed to reduce the use of imaging for low-back pain: a systematic review

“…One study assessed clinical decision support in a hospital outpatient clinic and found a statistically significant decrease in imaging in the intervention group. 33 The other assessed guideline distribution with audit and feedback and found no statistically significant results. 15 These results are consistent with those found in our review.…”

“…The authors found a statistically significant decrease in referrals for imaging of the spine (risk ratio 0.7, 95% CI 0.5 to 0.95); however, they did not account for clustering in the initial analysis, which decreased the validity of the result. We excluded 2 controlled before-after studies 33,15 because of study design. One study assessed clinical decision support in a hospital outpatient clinic and found a statistically significant decrease in imaging in the intervention group.…”